How To Determine The Long Term Care Workforce In Denmark

Transcription

1 IMPACT OF AGEING ON LONG-TERM CARE WORKFORCE IN DENMARK ERIKA SCHULZ SUPPLEMENT A TO NEUJOBS WORKING PAPER D12.2 JANUARY 2014 This paper aims to show the impact of population ageing on the demand and supply of long-term care workforce. As age is the major driver of the need for care the growth in the number of elderly and oldest old will increase the demand for long-term care services. In Denmark with a generous social assistance system is the provision of help and care to the elderly the responsibility of the municipalities. They are obliged to finance and organize help and care to all people in need of. However, also family member provide help and care to their relatives, but personal care is almost provided to partners. Thus, the increasing demand for help with practical duties and in particular personal care is a challenge for the local authorities. Until 2025 the demand for staff working in nursing and care is expected to increase by 22 % to 32 % depending on the underlying demographic scenarios. Although the employment is also estimated to increase, a significant shortage of nursing and caring staff is expected. New technologies, intensifying of international recruitment strategies, but also new ways of organization, financing, and provision of home care may help to deal with the expected shortage of care workforce. NEUJOBS Working Documents are intended to give an indication of work being conducted within the NEUJOBS research project and to stimulate reactions from other experts in the field. Texts published in this series are ultimately destined for academic publishing. The views expressed in this paper are those of the author and do not necessarily represent any institution with which he is affiliated. See the back page for more information about the NEUJOBS project. Available for free downloading from the NEUJOBS website ( DIW Berlin 2014

2 2 SCHULZ CONTENTS 1 Introduction Need of care and caregiving arrangements People in need of care Care settings home care and nursing home care and the role of informal caregiver Formal and informal care Informal caregivers Long-term care workforce current situation Factors influencing future long-term care workforce need Ageing populations and changes in dependency Significant increase in the number of elderly and oldest old Changes in dependency Changes in informal care potential Impact on the need of formal care and the long-term care workforce Changes in the number of people receiving formal care Changes in the demand for (public financed) formal care workforce Discussion of demand results Changes in labour force supply Development of overall labour force Shortage of care workforce expected Summary and discussion References... 33

3 IMPACT OF AGEING ON LONG-TERM CARE WORKFORCE IN DENMARK 3 LIST OF TABLES AND FIGURES Table 1 People with limitations in everyday tasks by age-groups and gender in Denmark Table 2 People aged 50+ with and without impairments in ADL and IADL in Denmark in Table 3 Share of persons aged 50+ providing informal care to someone inside or outside the household in Denmark Table 4 Characteristics of informal caregiver aged 50+ in Denmark (%) Table 5 Staff working in nursing and care in Denmark (FTE) Table 6 Assumption of population scenarios - Denmark Table 7 Demographic development in Denmark 2010 to Table 8 Development in the number of people with limitations in activities they usually do in Denmark 2010 to Table 9 Number of people aged 50+ with impairments in ADL or IADL in Denmark in 2010 and Table 10 Living arrangement of the elderly in Denmark in 2010 and changes between 2010 and Table 11 Changes in informal caregiver aged 50+ providing personal care on a regularly basis taken changes in living arrangements into account in Denmark Table 12 Recipients of permanent home help at home and in nursing homes in Denmark in 2010 and Table 13 People aged 65+ in need of care and care giving arrangements in 2025 (tough scenario) Table 14 People aged 65+ in need of care and care giving arrangements in 2025 (friendly scenario) Table 15 Table 16 Demand for staff in nursing and care in 2010 and 2025 in Denmark (persons in the main account care) Employment by sectors in Denmark estimations based on the results of the NEMESIS model Figure 1 Share of people with limitations in performing everyday tasks in Denmark 2010*... 6 Figure 2 Overview of people aged 65+ in need of care and care arrangements in Denmark in Figure 3 Age-profile of the population in Denmark 2010 and Figure 4 Population by age-groups in Denmark changes between 2010 und 2025 (%)... 17

4 IMPACT OF AGEING ON LONG-TERM CARE WORKFORCE IN DENMARK ERIKA SCHULZ SUPPLEMENT A TO NEUJOBS WORKING PAPER D Introduction Although Denmark has one of the lowest life expectancy for men and women among European countries a significant increase in the number of elderly and particular of the oldest old is expected. Denmark as one of the Nordic countries is well-known for the universal approach to welfare which takes over also tasks that are the responsibility of families in other European countries. Care services are offered to all residents in need of independently from their income, assets or family network. In Denmark elderly care is predominantly the tasks of the local authorities. Thus, an adequate provision of home care and nursing home care to meet the increasing demand is a challenge for the municipalities. In 2003, a free choice of care provider for home care was introduced, which leads to an outsourcing of help and care tasks to private for-profit providers. However, most of the care tasks in particular personal care are still provided by public employed personnel (Bertelsen and Rostgaard, 2013). One of the objectives of the Danish home help system is to encourage and enable the elderly to stay at home for as long as possible. Home care has a strict priority, however people in need of care can also choose between different kinds of accommodations suitable for the elderly and disabled. These include senior citizen residences, gated communities, assisted living units, nursing dwellings, and nursing homes (OECD, 2011). People in need of care generally pay the rent for living in a non-profit or conventional nursing home or dwelling. But they are eligible to receive public financed home help independently of their living place. Contrary to other European countries public financed home help comprises help with necessary practical duties (household chores) as well as personal care. Home help is provided to people in need of independent from potential informal caregiver and the amount of care needed. The amount of need of care is assessed by the communities. Family member take over care tasks, but mostly in addition to formal care. Solely informal personal care plays only a marginal role. The future need of long-term care workforce depends therefore to a high degree on the demographic development and the change in impairments in activities of daily living (ADLs) and instrumental activities of daily living (IADL), but not as much as in other European countries on the availability of potential informal carer. This report focuses on the impact of societal change on the need of formal care and the formal long-term care workforce. Erika Schulz is senior researcher at the German Institute of Economic Research (DIW) Berlin, eschulz@diw.de

5 IMPACT OF AGEING ON LONG-TERM CARE WORKFORCE IN DENMARK 5 The report is structured as follows: Section 2 provides an overview of the number of people in need of care and the realized care giving arrangements. Section 3 shows the current size and occupational structure of long-term care workforce. Section 4 discusses the factors influencing the future demand for long-term care workforce. In section 5 the changes in the supply of formal care workforce are discussed. Section 6 shows the results and discusses strategies to adapt supply to the growing demand. 2 Need of care and caregiving arrangements 2.1 People in need of care The demand for care services and the needed workforce depends on the number of people in need of care and their ability to perform every-day tasks by themselves. According to the OECD definition are people in need of care persons with a reduced degree of functional capacity, physical or cognitive, and who are consequently dependent for an extent period of time on help with basic activities of daily living (ADL), such as bathing, dressing, eating, getting in and out of bed or chair, moving around and using the bathroom. This is frequently provided in combination with basic medical care, prevention, rehabilitation or services of palliative care. Long-term care services also include lower-level care related to help with instrumental activities of daily living (IADL), such as help with housework, meals, shopping and transportation (Fujisawa and Colombo, 2009). Information on the quantity of people in need of care is rare. Two surveys provide information on dependency and impairments: the European Union Statistics on Income and Living Conditions (EU SILC) provides information for people aged 16+ living in private households and the Survey of Health, Ageing and Retirement in Europe (SHARE) provides information for people aged 50+ living in private households. The EU SILC asks for self-assessed impairments in daily activities. The question is For at least the past 6 months, to what extent have you been limited because of a health problem in activities people usually do? Would you say you have been severely limited, - limited but not severely or not limited at all? The Ageing working group of the European Commission used the share of people reporting severe limitations as a proxy for dependency rates. In the Ageing 2012 report these dependency rates are used to calculate the future number of dependent people and the future long-term care expenditure (EC EPC 2012). The EU SILC results for Denmark shows a relatively high variation in the share of people reporting severe limitation in the single age-groups across the surveyed years. This may be traced back to the small sample size. Another phenomenon is that contrary to other EU member states the share of dependent people increases only slightly with age. Figure 1 shows the share of people reporting severe impairments in performing every-day tasks and the share of people reporting limitations, but not severe for men and women in In general, the share of people with self-perceived

6 6 SCHULZ severe impairments increases with age, however the increase is only marginal from the age-group onwards and shows high variation for males and females. Contrary, the share of people reporting not severe limitations increases with age. Figure 1 Share of people with limitations in performing everyday tasks in Denmark 2010* 50,0 45,0 40,0 35,0 30,0 25,0 Total severe Males severe Females severe Total not severe Males not severe Females not severe 20,0 15,0 10,0 5,0 0, *) Share of people with severe impairments in activities they usually do for at least 6 months and share of people reporting not severe limitations in activities they usually do. Source: Eurostat, EU SILC; calculation of DIW Berlin. Based on these limitation rates and the Eurostat population the number of dependent people (severe limitations) and the number of people with not severe limitations in Denmark is calculated. 1 In 2010 around 371,000 people reported to have severe impairments in daily activities, thereof 169,000 males and 202,000 females (Table 1). The number of people with impairments in performing everyday tasks which are not severe is 930,000, thereof 401,000 males and 528,000 females. Around 24 % of the severe limited population is aged 65+; among men 21 % and among women 27 %. Females are living longer, but often they suffer from impairments in daily living due to longstanding illnesses. In total 90,000 people aged 65+ had severe limitations in activities they usually do in The share of elderly among people 1 The EU SILC survey is carried out in private households. As the probability to live in institutions increases with age, the prevalence rates in the older age-groups may be underestimated (EC EPC, 2012). But in Denmark is the share of people living in nursing homes relatively low.

7 IMPACT OF AGEING ON LONG-TERM CARE WORKFORCE IN DENMARK 7 reporting not severe limitations is slightly lower, 22% in total. The number of not severe limited elderly amounts to around 200,000. Table 1 People with limitations in everyday tasks by age-groups and gender in Denmark 2010 People with severe limitations People with limitations, but not severe Total Males Females Total Males Females Total Males Females Total Males Females in 1000 Age-structure in % in 1000 Age-structure in % Total Source: Eurostat, EU SILC; Huisman et al 2013; calculation of DIW Berlin. The SHARE survey of people aged 50+ living in private households provide information on impairments in activities of daily living (ADL) and instrumental activities of daily living (IADL). The share of people aged 50+ with impairments in at least 1 ADL is for men on average 8 % and for women 10 %. Only a small part of males reported impairments solely in IADL, around 5 %. The corresponding share for females is 11 %. A large share of males (87 %) and females (79 %) had no impairments at all. The SHARE results are shown in Table 2. In total some 180,000 people aged 50+ reported impairments in at least 1 ADL in Denmark, thereof 76,000 males and 103,000 females. Around 129,000 were aged 65+. Table 2 People aged 50+ with and without impairments in ADL and IADL in Denmark in 2010 Agegroups with at least 1 ADL no ADL with at least 1 IADL Males no ADL, no IADL Total with at least 1 ADL Females no ADL with at least 1 no ADL, IADL no IADL Share in % Total with at least 1 ADL no ADL with at least 1 IADL Total no ADL, no IADL in 1000 persons Source: SHARE wave 1, 2, and 4; weighted and pooled data; Huisman et al. 2013; calculation of DIW Berlin. Total

8 8 SCHULZ Contrary to the EU SILC results the SHARE survey shows a clear increase in impairments in ADL and IADL with age for both males and females. On average 6.3 % of people aged years reported impairments in ADL, but around 29 % of people aged 80+. The corresponding share for people reporting impairments in IADL are 5 % and 20 %. In 2010 around 340,000 people aged 50+ had impairments in ADL or IADL. 2.2 Care settings home care and nursing home care and the role of informal caregiver Formal and informal care Many people with impairments in ADL and IADL need the help of formal or informal caregiver, other are able to cope with their impairments themselves. The coping strategies as well as the amount of public financed care and help determine the need for formal care workforce. Denmark has a comprehensive social care system with the municipalities responsible for providing help and care to the elderly financed by taxes. A high share of care tasks are carried out by public employed nurses, caregivers or helpers. Additional, in most communities private for-profit providers provide home help almost with practical duties. All residents who need help with housework or personal care - even if the help or care is needed only for one hour per week - are eligible to receive home care irrespective of age, income, wealth or the potential of informal care givers (Schulz 2010). A basic principle is that the type of home should not dictate the offers of care to older people (OECD, 2011). Nursing and care is provided as temporary home help (with co-payments) or permanent home help (free of charge) at home and in nursing homes or in nursing dwellings. As permanent home help at home is given strict priority over caregiving in nursing homes, no new nursing homes have been constructed since 1987 (Strandberg-Larsen et al., 2007). Thus, nursing homes are in the process of being phased out. Various forms of service-enriched housing are being developed in their place with the active support of the municipal and national governments. The goal is to create non-institutional but supportive living arrangements for the elderly with varying levels of functioning. Such housing is often located near and linked with existing nursing homes, sheltered accommodation, daycare homes or day centers and/or community centers to maximize the use of personnel and facilities, as well as to ensure convenient access to nursing and other community services (Brodsky et al., 2003). In 2010, in Denmark in accommodations suitable for the persons in need of care (nursing homes, service enriched housing, sheltered accommodations) around 47,000 beds exist, that is 51 beds per 1000 persons aged 65+ (OECD Health Data, 2013a). The number of dwellings in nursing homes is 37,000, in residential homes 7,000, and in protected homes 1,500. Additional 34,500 general dwellings for the elderly exists (Statistics Denmark, 2014). In 2010, around 42,000 persons received help and care in nursing homes or nursing dwellings (public and private for-profit). The majority (40,000) was at least 65 years old. Home help at home was provided to 177,000 persons, thereof 149,000 at least 65

9 IMPACT OF AGEING ON LONG-TERM CARE WORKFORCE IN DENMARK 9 years of age. Help is given with necessary practical duties, personal care or both. Almost all people living in nursing homes or nursing dwelling receive personal care or both personal care and help with practical duties (41,500). People at home receive to a high share only help with practical duties. In 2010, 87,000 people receive this kind of help, around 72,000 receive both personal care and help with practical duties and around 18,000 receive solely personal care. As all people in need of help and care are eligible to receive the needed care, all dependent people should be covered by the home help scheme. Figure 2 gives an overview of the estimated amount of people aged 65+ in need of care and the care giving arrangements. According to the EU SILC around 90,000 persons aged 65+ reported longstanding severe limitations, and around 200,000 aged 65+ reported limitations which were not severe. Home help is provided to around 190,000 people aged 65+. The need of help and care is assessed by the municipalities and not all people reporting limitations are in need of formal help and care as they are able to cope with their impairments themselves with or without the help of informal caregiver. We can also compare the people receiving home help with the calculated number of people with impairments in ADL and IADL. According to the SHARE survey around 125,000 people aged 65+ had impairments in ADL in ,000 people aged 65+ received home help as personal care or both personal care and help with practical duties. As the SHARE data are only an estimation is can be assumed, that the aim to provide personal care to all people in need of are is achieved. According to SHARE, around 107,000 people aged 65+ were impaired in IADL. In 2010, around 72,000 receive solely help with practical duties (in nursing dwellings and at home). The other may cope with their impairments themselves or they receive help from family caregivers. Based on the SHARE results an estimated number of 35,000-40,000 people aged 65+ rely on informal care or are able to cope with their impairments themselves. Information on the number of people using private financed home help or living in private financed nursing homes or nursing dwellings is not available. As all people are eligible to receive public financed help and care it can be assumed that the amount of solely private financed help and care is insignificant (meals on wheels are not taken into account). The SHARE survey provides also information on informal caregiving. According to this data, people receive also informal care solely or in combination with formal help and care. In 2010, 70,000 persons provided personal care to someone inside the household and estimated around 20,000 to someone outside the household. According to the OECD health data only 19,000 people provided informal care in 2006.

10 10 SCHULZ Figure 2 Overview of people aged 65+ in need of care and care arrangements in Denmark in 2010 EU SILC: People 65+ reporting severe limitations in activities they usually do due longstanding illnesses 89,500 EU SILC: People 65+ reporting not severe limitations in activities they usually do due longstanding illnesses 201,000 SHARE: people 65+ with impairments in at least 1 ADL 125,000; people 65+ with impairments in IADL 107,000 People 65+ receiving home help People 65+ receiving informal care or no care 189,000 around 35,000-40,000 according to SHARE data in nursing at home with help with in nursing at home receiving homes personal solely homes informal care (50+) no care thereof care both practical private inside the from persons but may be personal care solely personal care duties financed household outside the private or both* and practical insignificant (70,000) household financed 39,400 duties number (21,000) help 39,800 14,500 63,200 71,300 n.a. (OECD: 19,000) n.a. *) personal care and help with necessary practical duties. Source: EU SILC; SHARE data; OECD 2013; calculation of DIW Berlin Informal caregivers In general, the available (publicly financed) long-term care services and the required co-payments have a significant influence on the amount of informal care provided by the family and other informal caregiver. In the Nordic countries like Denmark traditional the state is responsible for providing care to people in need of. Permanent home help is provided to all people in need of and requires in general no co-payments. People living in nursing dwellings have to pay for the rent, but the receive help and care is free of charge. Family members who want to take over care tasks for their relatives can choose to be employed by the municipalities. The number of working hours depends on the number of hours the care receiver is granted for. The family members who act as public employees are entitled to all types of social security. However, this regulation is very rarely used (Pfau-Effinger et al., 2011). In general, it can be expected that informal care plays a smaller role than in other European countries. The SHARE survey which comprises only people aged 50+, includes specific questions on the provision of personal care to people inside and outside the household. Information on help and care provided to someone outside the household is distinguished between types of help and care provided, and how often help and care is provided. Information on provided care to someone inside the household relies on personal care provided on a regular basis for at least three months. Information on care to someone outside the household distinguishes between all kind of help and care, personal care, and personal care on an almost daily basis. The questionnaire asks about care provided in the last 12 months or since the last interview.

11 IMPACT OF AGEING ON LONG-TERM CARE WORKFORCE IN DENMARK 11 The share of informal caregivers aged 50+ inside and outside the household is shown in Table 3. In Denmark 4.6 % of people aged 50+ provide care on a regular basis inside the household, 3.8 % of males and 5.5 % of females. Table 3 Share of persons aged 50+ providing informal care to someone inside or outside the household in Denmark Share of people aged 50+ providing regular personal care to someone inside the Males Females Total in% household personal care to someone outside the household almost daily (0,66) Personal care to someone outside the household all kind of help and care outside the household Source: SHARE wave 1 and 2; pooled data, weighted; calculation of DIW Berlin. The share of people providing care to someone outside the household depends strictly on the kind and amount of help provided. Focusing on all kinds of help and personal care given to someone outside the household, the share is 46 %. The share of people providing any kind of help and care is significant higher for males than for females. Males provide often help with financial tasks or doing repairs. Focusing only on the provision of personal care to someone outside the household changes the picture: Around 6 % of people aged 50+ provide personal care to someone outside the household. This is a significant lower share as in the case were all types of help and care are included. The share of females providing personal care is twice as high as of males indicating that personal care is mainly the tasks of women. If we go a step further and focus only on personal care provided on an almost daily basis, which is comparable with the care giving inside the household, again the share of caregivers is lower. Around 1 % provides personal care on a daily basis to someone outside the household. As the sample size is small only a few persons reported to provide regularly personal care. Thus, the results have to be interpreted with caution. If we focus only on personal care provided on a regular (inside the household) or almost daily (outside the household) basis, around 6 % of people aged 50+ provide such kind of care, that is 70,000 inside and 21,000 outside the household in Table 4 shows the characteristics of informal caregivers aged 50+. Around three quarter (72 %) of people providing regular personal care to someone outside the household is females and a high share is aged years (90 %). That means a high share of informal care provided outside the household is done by people in working age. Care outside the household is given to a parent (30 %) or to other members of the family (14 %). Care giving inside the household is dominantly caregiving to a partner (85 %). Partner-care is provided by males and females (share females 56 %), and the caregiver is therefor also in older age (share 70+ is around 39 %).

12 12 SCHULZ Table 4 Characteristics of informal caregiver aged 50+ in Denmark (%) Characteristics of caregiver Share of people providing personal care to someone outside the houshold (almost daily) inside the household (regulary) share of caregiver aged share of female caregiver share caregiving to one parent share caregiving to other family member* share caregiving to partner share caregiving to other* 5.13 *) Except child. Source: SHARE wave 1 and 2; pooled data; weighted results; calculation of DIW Berlin. In 2010, a survey on informal eldercare and the relation to employment was carried out in the three Nordic countries, Denmark, Norway, and Sweden (Jakobsson, Kotsadam, Szebehely, 2013). In general, the survey data for Denmark are similar to the SHARE results. People aged years were asked Have you helped a family member, relative, friend, or neighbour who needs help in everyday life owing to long-term illness, disability, or old age at least once a month during the last year (e.g., with cleaning, paper work, personal care, or going outside)? Help giving was distinguished in parental care, disabled child care, partner care, or other. In Denmark 48.8 % of the respondent reported to provide some kind of help, 27.5 % to a parent, 4.5 % to a disabled child, 5.2 % to a partner and 24.2 % to another person. As only people in working age were interviewed partner care plays only a marginal role. Help to another person include also help provided to friends or other relatives which may explain the high share of persons providing any kind of help. Every fourth person provides help to parents. On average around 12 hours of help are provided per month. People with low income, but also people with a high education provide significant higher amounts of parental care than the average. Age and marital status have no significant effect. 3 Long-term care workforce current situation In Denmark the provision of long-term care services is one field of social activities of the municipalities. For their social tasks they employ nurses, social workers and other staff for the fields of social services like residential care or care to elderly, disabled, and people with special needs. The employees carry out different kinds of activities and it is not possible to identify exactly the activities related to long-term care giving. In 2010,

13 IMPACT OF AGEING ON LONG-TERM CARE WORKFORCE IN DENMARK 13 in total around 160,000 employees (FTE) are working in nursing and care, thereof 98,000 in care activities, around 6,400 in preventive measures for the elderly and disabled, and 2,900 in rehabilitation measures. We selected the main account care to identify the employees working in long-term care. This is only a raw estimation, because Bertelsen and Rostgaard (2013) mentioned that around 111,200 FTE are working in elderly and disabled care (residential care, home care, day centres, preventive visits, rehabilitation). As we want to focus on long-term care measures (excluding rehabilitation and preventive measures) we decided to use the main account care solely. Statistics Denmark confirmed that this statistics comprises home help at home and in institutions (Mr Hougaard, personal interview). Table 5 provides the number of employees working in the main account care measured in full-time equivalents (FTE). The data are provided by the municipalities. The staffs mainly active in care measures for elderly, handicapped and juveniles with special needs is included. In 2010, in the field of care around 98,000 FTE were employed. The number of FTE was lower in 2011 and 2012, e.g. due to changes in the accounting system. Around 75,000 FTE were social workers including personal carers, around 8,000 FTE were nurses. Table 5 Staff working in nursing and care in Denmark (FTE) Occupations Staff working in the field of care Total Management Nurse Physiotherapist Catering officer etc. (matron) (-2010) Occupational therapist Teacher (-2010) Pedagogue, Teacher (2011-) Pedagogue (-2010) Psychologist Social worker etc Administrative work (-2010) Administration, Office and secretary work (2011-) Office and secretary work (-2010) Caretaker etc Pedagogue assistant etc. (-2010) Social and health workers etc. (-2010) Social and health workers, Pedagogue assistant etc (2011-) Social and health care assistants etc Cleaning etc Assistant in kitchen etc. (-2010) Catering officer etc. (matron) (2011-) *) Staff in all measures for elderly, handicapped and juveniles with special problems, but no child care. Source: Statistics Denmark.

14 14 SCHULZ Hohnen (2011) provides some additional information on the working conditions of care workers. Care work is characterized by permanent contracts, and it is generally part-time (30 hours a week). There is a high turnover and 30 % change job every year. Elderly care is demanding both physically and emotionally. The level of sick absenteeism is about three times as high as it is for employees on average, and care workers have a 61 % higher risk of requiring early retirement. As the work tasks are determined, care workers feel to have a low degree of influence over work tasks. Low wages and gender wage differences have led to strikes in the past, and some improvements could be achieved. The introduction of the free choice of care provides has led to an increase in the number of private for-profit suppliers. In 2010, 413 private supplier of home help were active, in 2012, 488. Not all communities have outsourced help and care tasks, thus in 2010 fife municipalities had no private for profit supplier. Private for-profit suppliers are mainly engaged in practical duties like housework and cleaning. Personal care is still the tasks of public suppliers in almost all municipalities (see also Fersch and Jensen, 2011). In 2010, the number of employees in private for-profit provides of home care was 3,800 FTE (Bertelsen and Rostgaard, 2013). Although the statistics on clients in nursing homes and nursing dwellings shows that 680 persons lived in private nursing homes, no information on the number of employees in private nursing homes exists. 4 Factors influencing future long-term care workforce need 4.1 Ageing populations and changes in dependency Significant increase in the number of elderly and oldest old In 2010, Denmark had 5.5 million inhabitants, thereof 0.9 million aged 65+ and 0.2 million aged 80+. The share of elderly is around 16 %. The future population is determined by the size and age-structure in the base year (stock) and by the flow variables birth, death and migration. While the migration flows have an influence mostly on the number of people in working age, the fertility rates and the changes in life expectancy determines the share of elderly and oldest old in total population. Thus the ageing process will be mostly influenced by the ageing of the population stock, the fertility rates and the life expectancy. The NEUJOBS demographic scenarios tough and friendly assume a further increase in life expectancy (LE) for males and females (Huisman et al., 2013). The increase in LE at birth is caused by a reduction in mortality rates in the middle and in particular in the higher ages. The Netherlands Interdisciplinary Demographic Institute (NIDI) which has carried out the demographic scenarios provides the calculations of the LE at birth,

15 IMPACT OF AGEING ON LONG-TERM CARE WORKFORCE IN DENMARK 15 at the age of 65, and at the age of 80 for the base year and the year 2025 (Van Der Gaag, internal provision of data). In 2010, the LE at birth was 77.2 years for men and 81.4 years for women. Men aged 65 could expect to live more than 17 additional years, women more than 20 years (Table 6). Men aged 80 could expect to live 7.7 additional years and women 9.4 years. In both scenarios the LE is expected to increase, but to a higher degree in the friendly scenario. In the friendly scenario the LE at 65 is assumed to increase by 3.1 years for males and 2.8 years for females. People aged 80 can expect to have a 1.9 (men) and 1.8 (women) higher life expectancy. In the tough scenario the assumed increase in LE65 is with 1.1 year for males and 1 year for women significant lower. The LE at 80 is expected to increase by 0.5 (males and females) years. Table 6 Assumption of population scenarios - Denmark Friendly Tough Fertility rate LE at birth males LE at birth females LE at age 65 males LE at age 65 females LE at age 80 males LE at age 80 females Net migration per year (1000) Source: Eurostat, Huisman et al.2013, Van Der Gaag (internal data). The share of elderly in total population is also influenced by the shrinking size of following generations due to the fertility rate which is below the replacement level. In 2010, the fertility rate was 1.87 that means that the following generation is around 10 % smaller than the current once. In the tough scenario the fertility rates are assumed not to change, in the friendly scenario an increase up to 1.94 is assumed which is still below the replacement level (2.1 children per women). In 2010, Denmark realized net immigrations of 15,300 persons. It is assumed that Denmark will have net immigrations also in the future. In the friendly scenario a yearly net migration of 18,000 is expected and in the tough scenario of around 6,000. The increase in LE, the net migrations and in the friendly scenario the increase in fertility is estimated to lead to an increase in total population in Denmark. In the tough scenario the population will increase by 2.2 % and in the friendly scenario by 5.3 % (Table 7). That is an increase by 122,000 persons in the tough and 294,000 persons in the friendly scenario. In 2025 around every fifth inhabitant will be at least 65 years old, around 200,000 in the tough and 280,000 in the friendly scenario.

16 16 SCHULZ Table 7 Demographic development in Denmark 2010 to 2025 Age Changes 2025/ groups tough friendly tough friendly tough friendly tough friendly in 1000 persons in % age-structure in % total Source: Huisman et al., 2013; calculation of DIW Berlin. As the need of long-term care increases significantly from the age 75 onwards, the size and share of the oldest old, in general defined as people aged 80+, are of particular interest. In 2010, around 230,000 people were aged 80+ in Denmark. The share in total population was 4.1 %. Until 2025, the number of the oldest old is expected to increase by 85,000 (friendly) and 34,000 (tough). That is a growth of 37 % in the friendly and 15 % in the tough scenario. In 2025 around 5.4 % (friendly) and 4.6 % (tough) of population will be at least 80 years old. The shift of the baby-boomer born at the end of the fifties and the beginning of the sixties at higher ages and the effect of the demographic components on the agestructure of the population is shown in Figure 3. The baby-boomer which dominate the age-groups in 2010, will dominate the age-group in The different assumption on the further increase in LE leads to the differences in size of people aged 75+. The different assumptions in fertility rates can be seen in the different size of the youngest age-groups, and the assumptions concerning migration can be seen in the difference between the friendly and tough curve in the younger and middle working age-groups. The changes in the single age-groups are shown in Figure 4. In the youngest age-group 0-4 years a slightly increase in population is calculated, while in the next age-group5-9 years only marginal changes are expected. The number of people in young working age-groups will increase, while the number of people in prime working age is expected to decline. For elderly workers and in particular for people at least 70 years old a significant increase is estimated. In particular in the friendly scenario the pressure on care provision due to demographic change is estimated to increase. As oldest old people have a higher risk of multi-morbidity and impairments in more than 1 ADL the needed amount of care will show a higher growth than the population in these agegroups. Additional, mental illnesses are common among the oldest old, which requires additional time for advice and attendance.

17 IMPACT OF AGEING ON LONG-TERM CARE WORKFORCE IN DENMARK 17 Figure 3 Age-profile of the population in Denmark 2010 and increase in fertility baby-boomer t increase in LE f Source: Huisman et al. 2013; calculation of DIW Berlin. Figure 4 Population by age-groups in Denmark changes between 2010 und 2025 (%) 80,0 60,0 40,0 2025t 2025f 20,0 0,0-20,0-40, Source: Huisman et al. 2013; calculation of DIW Berlin.

18 18 SCHULZ Changes in dependency The continuing increase in LE in the past on the one hand and the increase in the number of dependent people in particular among the elderly and oldest old on the other hand have stirred the discussion on the relationship between these two trends. The literature provides contradictory theoretical positions on this question. There are three hypotheses: Fries et al (1980, 1989) stated that the additional years are to a high share years in good health, thus the share of the life span in bad health will decline as the LE increases due to the postponed onset of chronic diseases. This hypothesis is called compression of morbidity. In contrast, Gruenberg (1977) stated that the additional years are to a higher share years in bad health ( expansion of morbidity hypothesis). The medical progress leads to an expansion of the life span due to reduction in mortality of several diseases, but the additional life span is not free of illnesses. Chronic diseases will expand. The third hypothesis stated by Manton (1982) assumes that the additional life years do not change the relation of years in good health and years in bad health ( dynamic equilibrium hypothesis). Several authors carried out studied to show the empirical relevance of the mentioned hypotheses (for example Lafortune et al., 2007; Robine et al., 1993; Manton et al., 1998; Robine et al., 2003), but no clear trend across the studied countries could be shown. Some European countries showed evidence for a compression of morbidity while in other countries the data supported an expansion of morbidity (Robine et al., 2009). In Denmark the proportion of health life years at age 65 remained almost stable in the past (EHLEIS Country Report Denmark, 2013). Thus, we used constant rates of limitations and constant rates of impairments in ADL to calculate the future development of people in need of care. As the EU SILC covers only people aged 16+, the dependency rate of people aged is used for the total population aged under 20 to calculate the total number of dependent persons. Table 8 shows the development of people with limitations based on the EU SILC data and the both demographic scenarios tough and friendly. As the share of people reporting severe impairments due to longstanding illnesses is held constant, the changes in dependent people show the pure demographic effect. The number of dependent people (severe limitations) is expected to increase by 11,000 in the tough scenario and by 24,000 in the friendly scenario. That is an increase of 3 % (tough) and 7 % (friendly). Due to the changes in the size and age-structure of the population the number of people with severe limitations under 55 years old is expected to decline, while the number of elderly with severe limitations will increase. The highest increase is expected for severe limited people aged years with 45 % in the tough and 56 % in the friendly scenario. Thus, the share of severe limited elderly (65+) will increase from 50 % in 2010 to 53 % (tough) and 55 % (friendly) in The number of severe limited people aged 65+ will increase by 20,000 (tough) and 28,000 (friendly).

19 IMPACT OF AGEING ON LONG-TERM CARE WORKFORCE IN DENMARK 19 Table 8 Development in the number of people with limitations in activities they usually do in Denmark 2010 to Changes between 2010 and 2025 tough friendly tough friendly tough friendly Agegroups not not not not not not not severe severe severe severe severe severe severe severe severe severe severe severe severe severe limitations limitations limitations limitations limitations limitations limitations in 1000 persons in 1000 persons in % Total Source: Eurostat, EU SILC; Huisman et al. 2013; calculation of DIW Berlin. As the Danish home help system provides also help and care to people with low levels of help and care needed, the development of people reporting not severe limitations in daily activities is also of interest. The number of not severe limited elderly (65+) will increase by 43,000 in the tough and 65,000 in the friendly scenario. That is an increase of 21.3 % (tough) and 32.3 % (friendly). The SHARE results using the share of people aged 50+ with impairments in at least 1 ADL shows a higher growth in people with impairments in ADL compared to the development of severe limited people aged 50+: The number of impaired people aged 50+ is expected to increase by 16 % (tough) and 26 % (friendly), and the number of severe limited people aged 50+ according to the EU SILC results is expected to increase by 12 % (tough) and 17 % (friendly). According to the SHARE data the number of people aged 50+ with impairments in ADL is expected to amount 208,000 in the tough and 225,000 in the friendly scenario, thereof 150,000 (tough) and 166,000 (friendly) aged 65+ (Table 9). As home care comprises also help with necessary practical duties, the development of people reporting solely impairments in IADL have also to be taken into account. In 2025 around 132,000 (tough) and 145,000 (friendly) people aged 65+ will have impairments in IADL. That is an increase by 23 % (tough) and 36 % (friendly). Both calculations indicate a significant increase in the number of severe limited people as well as in the number of impaired people under the assumption of constant disability rates. They show that the expected population ageing will be a challenge for the municipalities.

20 20 SCHULZ Table 9 Number of people aged 50+ with impairments in ADL or IADL in Denmark in 2010 and Changes between 2010 and 2025 Age-groups 2010 tough friendly tough friendly tough friendly in 1000 persons in % with impairments in at least 1 ADL with no impairments in ADL, but in IADL with no impairments in ADL and in IADL Source: SHARE wave 1, 2, and 4; weighted and pooled data; Huisman et al. 2013; calculation of DIW Berlin. 4.2 Changes in informal care potential In Denmark the future development of informal caregivers is influenced by the changes in living arrangements because informal caregiving is almost caregiving inside the household to a partner. Changes in female labour force participation are expected to have only a marginal impact due to two facts: 1) female activity rates are similar to that of males among high educated people, slightly lower for middle educated people, but significant lower for males and females with low education level. Thus, further changes in female labour force participation are almost due to increase in education; 2) informal care is predominately provided inside the household by elderly (not working) people to their partner. However, below we also discuss the relationship between female employment and informal caregiving. Changing living arrangements The NEUJOBS demographic scenarios provide information on the changes in living arrangements of the population by age-groups and gender. The NEUJOBS demographic projections distinguish between following living arrangements: singles, children under the age of 15, children between 15 and 24 of age living in parental home and are economically dependent, single parents, couples with children, couples

21 IMPACT OF AGEING ON LONG-TERM CARE WORKFORCE IN DENMARK 21 without children and other households. The living arrangements differ between the age-groups and gender, but they are also influenced by education levels. The projected changes in living arrangements are calculated using the changes in population by age, gender and education level. Other influencing factors, like changes in household building behaviour and changes in divorce behaviour, are not taken into account. Thus, the demographic development and the changes in education levels determine the changes in living arrangements. The Table 10 shows the living arrangement of people aged 50+ in 2010 and the changes between 2010 and 2025 for the two demographic scenarios. The category other comprises single parents, couple living with children and other households. In 2010, around 60 % of people 50+ lived with a partner and 26 % lived alone. The share of single households increases with age. Due to the higher LE of females, women are to a higher share singles than men, in particular in the highest age-groups. Table 10 Living arrangement of the elderly in Denmark in 2010 and changes between 2010 and 2025 Population Living arrangements Population Living arrangements Population Living arrangements Age- Total Single Couple Other Males Single Couple Other Females Single Couple Other groups in 1000 Share in %(changes in %-points) in 1000 Share in %(changes in %-points) in 1000 Share in %(changes in %-points) Sum Changes between 2010 and 2025 in the tough scenario Sum Changes between 2010 and 2025 in the friendly scenario Sum Source: Huisman et al 2013; calculation of DIW Berlin. The expected future changes in living arrangements are different between males and females. The share of females (50+) living with other persons in the same household is estimated to decline in both scenarios, while the contrary effect is expected for males. The increase in LE 65+ is estimated to be nearly the same for males as for females with the consequence that the gap in LE between elderly males and females will not change.